Naturopathic Perspectivesby Jason Barker, ND

The Liver Cleanse andGallbladder Flush: SeparatingFact from Fiction

Liver support and cleansing are popular topics inalternative medicine. Liver support is perhaps one of themost widely employed therapeutic options in standard-of-care naturopathic medicine. It would seem that treatingthe liver is an integral step in the journey from disease towellness for a huge range of medical complaints to thenaturopathic physician. Liver cleansing has a rich historicalbackground based in eclectic medicine and provides afoundation on which general health restoration may befounded. Despite this, liver cleansing remains a little-researched area of modern medicine. Scientific study ofbotanical medicines and a handful of nutraceuticals haveprovided sound evidence of liver condition-specific efficacy,yet no studies exist in which liver cleansing as a whole hasbeen explored. The therapeutic success of liver cleansingat this time is mainly anecdotal; to bring this therapy intogreater focus requires a case series or clinical study. Whatwe do have is an increasingly growing field of research thatis defining how liver-specific nutrients work as protectiveand restorative medicine.

Liver Cleansing DefinedLiver cleansing can be loosely defined as process in

which items with liver-specific restorative benefits are takenorally by the patient, in orderto assist with removal of storedchemicals that create negative health effects from withinthe liver, and to improve liver function so that the bodyas a whole can better utilize the organ for its physiologicpurposes. Liver-cleansing protocols may also involve othertherapies such as colonies, saunas, or dry skin brushing, allof which are integrated for a systems approach to treatingliver conditions. The liver, being the primary organ of detoxfor both exogenous and endogenous chemicals, is itselfaffected by the toxicity and overall load ofthe compounds towhich it is exposed, which is also affected by its immediatesupply of nutrients and molecules needed for Phase I and IIreactions.

Liver cleansing may be indicated as a result ofenvironmental exposures, such as excessive prescriptionmedications and other drugs (cigarettes, caffeine, alcohol,etc.), heavy metals, food additives, pesticides, herbicides,solvents, and any other chemicals for that matter. Livercleansing is also indicated in chronic disease and otherstates of inadequate health, depending on the condition.

What are we talking about when we refer to a livercleanse? What are we trying to accomplish, and which toolshave the greatest efficacy? Liver cleansing is big businessoutside the clinician's office. A brief Internet search usingone popular search engine and the term "liver cleanse"resulted in 2,130,000 results. A large number of theseresults - the first ten or so pages, anyway - refer to theinfamous "gallbladder flush." The gallbladder flush carries aseemingly mystical notoriety on the multiple Internet pagesprofessing its wonders, with many patients enthusiasticallyrecommending the procedure after having experienced itthemselves.

The gallbladderflush to which lam referring will producemultiple greenish "stones" after the person consumesvarying combinations of olive oil, apple or grapefruit juice,water, and Epsom salts. Indeed, each Internet resourceproviding information also insists on selling its own specialliver cleanse supplement that users are instructed to usealong with the liver flush. While these sites are rampant,there are no studies that show any clear benefit from thesecleanses. However, it is well-known among the scientificmedical community that the "stones" produced from theinfamous gallbladder flush are not cholesterol gallstones. Itappears that there are only two case reports investigating theutility of the gallbladder flush; these were briefly discussedin this journal (November 2005). In short, one report^reiterated the theory that the "gallstones" produced by theflush are merely an amalgam of the ingredients ingested toinstigate the flush - in other words, no true gallstones wereproduced after the stones produced from the flush were

144 TOWNSEND LETTER - DECEMBER 2007

dissected. The second report verified passage of gallstonesby comparing before and after ultrasound analysis of onepatient's gallbladder contents.* It would appear the juryis out on the efficacy of the gallbladder flush using theaforementioned ingredients until more rigorous study canbe undertaken.

Liver-Cleansing Nutrients

Fortunately, there is much more to liver cleansing thanthe general liver flush, although "flushing" the liver seemsto be, in theory, an important step in maintaining andregaining liver health. If we are to accept the liver flush as auseful tool, the only benefit it does provide is the expellingof bile (and stones?) from the liver and gallbladder. It doesnot provide any direct benefit for the individual cellularmechanisms of the liver, other than possibly ridding theliver of bile (which is continuously manufactured), and thegallbladder also releases bile any time fats are consumed inthe diet, regardless of plant or animal origin.

What works for "cleansing" the liver, and how can wedescribe it in more exacting words? The following are someof the more widely employed agents for use in liver health,be it for "cleansing" or "support."

Methionine: This essential amino acid is often found in liverformulations. It can be considered a liver-defense nutrient,as its main role is to promote synthesis of the powerfulantioxidant glutathione. In turn, glutathione can be used toprevent toxic liver damage from the drug acetaminophen.However, as an individual supplement, it can be cost-prohibitive. Another one of the metabolic end-products ofmethionine metabolism is the amino acid taurine, which isa major contributor to bile acid conjugation. Conjugationis the marriage of taurine to bile salts, which then allowsbile to act as a detergent in fat absorbtion. Methioninehas been linked to liver toxicity in those with severe liverdisease, as well as in those undergoing long-term parenteralnutrition.'' However, these problems are seen with the useof excessively high doses of methionine that are far beyondthose found in liver-supportive products.

Choline: Choline is a nutrient that is involved in liver fatmetabolism. Choline can be synthesized in the body. Itsmain action in the liver is in fat transport; the action ofcholine is often referred to as "lipotropic," meaning it assistswith fat removal. Deficiency of choline contributes to liverdisease in the form of fatty liver and resulting damage.While choline deficiency and resulting disease is rare, it isavailable in protein-rich foods such as meats, eggs, beans,and legumes, among others.

Greater Celandine (Chelidonium mafus): This herb has astrong traditional use in liver disease. However, it is nowmore commonly used for cases of "indigestion" than forliver disease; it has recently been implicated as a causativefactor in cases of hepatotoxicity. '̂̂ Older studies on GreaterCelandine have shown it to be a potent producer of bile

and pancreatic digestive enzymes.^ Proponents of itsuse have claimed the herb has two opposing actions: itis thought to relieve gallbladder spasmŝ and to stimulatea hypo-functioning gallbladder.'̂ Other effects of GreaterCelandine qualify as liver-protective; animal studies showeda protective effect ofthe herb when exposed to hepatotoxicagents.'"'" Use of this herb as part of a liver protective/cleansing plan should be undertaken by those with athorough understanding of its safe-dosing use in liver-supportive protocols.

Fringe Tree (Cbionanthus virginicus): This herb also has astrong history for treatment of liver conditions and was usedas a choleretic, or bile flow stimulant. There are no modernstudies looking at the physiologic basis for its use.

Black Radish (Raphanus sativus): The root of this plantwill stimulate upper gastrointestinal tract secretions as wellas bile flow. It is indicated in conditions of sluggish flowand generalized liver disease.'̂ Because it is a choleretic, itshould be used with caution in gallbladder disease wherestones are present. There are no clinical studies looking atthe clinical efficacy of this herb.

Burdock (Arctium lappa): Burdock is thought to have strongantioxidative properties that lend to its hepatoprotectiveproperties. Clinically, burdock has been shown to improvethe biochemical and pathological markers (decreasedcytochrome P-450, increased serum triglycerides, lipidperoxidation, elevated serum transaminase, and reducedNADPH-cytochrome C reducatase) of liver damageinduced by experimental exposure to ethanol andcarbon tetrachloride.'' In a similar study looking at thehepatoprotective effects, burdock was also shown to protectthe liver from the toxic metabolites of acetaminophen aswell.''

Dandelion Root (Taraxacum officinale): Considered anoverall digestive tonic, dandelion is found incorporated inmany liver-specific products. The use of this particular herbis heavily influenced more so historical use rather than thefindings of modern study. Yet, this is another plant withemerging details that validate its historical use as a liver herb.Dandelion has been employed as a digestive tract herb,used for treating indigestion, gas, and anorexia. For liver-specific complaints, it is used for treating gallstones and as abile flow stimulant. One constituent of the root, taraxacin, isthought to increase bile flow in laboratory studies.'̂

Milk Thistle (Silybum marianum): Perhaps the most welt-known and researched liver herb (also one ofthe top-sellingherbs year after year in the US and elsewhere), milk thistleprovides the foundation of all liver-specific treatment.The properties of this herb are best expressed as liver-protective; an oft-repeated benefit is the ability to preventcellular damage from toxins by inducing changes in livercell membranes. Milk thistle is also widely reputed as a

TOWNSEND LETTER - DECEMBER 2007 145

Liver Cleanse and Gallbladder Flush

liver cell regenerator, an exclusive property limited to thisherb only. Silymarin, the active constituent in milk thistle,has the ability to inhibit the enzyme beta-glucuronidase,which prevents hepatic cellular injury by reducing thisenzyme's ability to convert glucuronide conjugates intotoxic metabolites in the liver and intestine.'*'

Turmeric (Curcuma longa): Turmeric is a traditionalAyurvedic liver herb that purportedly stimulates thegallbladder and has antioxidative, anti-inflammatory,antifungai, and antibacterial properties. The main activeconstituent of turmeric is curcumin, a yellow-coloredpigment. The anti-inflammatory, immunostimulatory, andanticancer effects of this herb are well-known and makeit the subject of ongoing research.'^'^ Turmeric is alsothe subject of much investigation into its liver-protectivequalities. Curcumin is showing promise as a preventiveagent in alcohol-induced liver enzyme elevation^" andin experimentally induced liver cirrhosis.^' Investigatorsconclude that curcumin exerts its protective effects byimproving antioxidant status and decreasing oxidation offats in the liver.

Artichoke (Cynara scolymus): Artichoke is a potent herb inthe realm of cholesterol metabolism and liver health. Themain active constituents of artichoke, cynarin, chlorogenicacid, caffeic acid, and polyphenol and flavonoid compoundsare thought to contribute to the plant's ability to regenerateliver cells, lower serum cholesterol and triglycerides, andact a digestive tonic.̂ ^ And the prior reference claims thatartichoke is an effective choleretic as well. Artichoke isseemingly incorporated in relatively few liver products;however, from the data revealing its effect on overallcholesterol metabolism and choleretic effects, it may makea useful addition to any liver protocol.

Liver CleansingIndications for a liver cleansing protocol are varied.

However, as stated earlier, addressing the liver is part ofa foundational approach to overall health and thus shouldbe considered by clinicians as part of a treatment plan.An important aspect of preparing for a liver cleanse is toaddress the purpose(s) behind it. Liver protocols result in themost success when lifestyle alterations (diet) are continuedbeyond the period of treatment. Simply following a liver-specific protocol for a week or two will provide no reallong-term relief if permanent changes are not made.

There are numerous, high-quality, liver-specific productsavailable today. This author advises that liver-supportiveprotocols only be undertaken under the care of a clinicianwith an understanding of the objectives behind liversupport. Adequate preparation for a liver protocol shouldbe undertaken. A shift in dietary habits should precedethe cleanse by one to two weeks. The cleanse itself willbe rigorous enough, without the added "shock" of sudden

discontinuation of habitual foods rich in fats, sugar, andcaffeine. Other important aspects of a liver cleanse includea fiber supplement, colonies, saunas, and exercise. Each ofthese are important contributors to assisting the body withelimination, which is an integral part of any liver protocol.Frequency of said protocols will vary on a person's state ofheaith. Typically a period of several months in between eachcleanse is advised. These protocols are typically rigorous,and those undergoing them may be more compliant andderive the greatest benefit.

Notes1. Google Internet search: 'liver cleanse.' Accessed August 31, 2007.2. Sres CW, Brooker). Could these be gallstones? Lancet. 2005;365:1388.3. Savage AP, O'Brien T, Lamont PM. Br I Surg. 1992 Feb;79{2):168.4. Btaiche IF, Khalidi N. Parenteral nutrition-associated liver complications in

children. Pharmacotherapy. 2002;22:t88-2n.5. Stickel F, PoschI C, Seitz HK, et al. Acute hepatitis induced by Greater

Celandine (Chelidonium majus). Scand / Caslroet^terol. 2003 May;38(5):565-8.

6. BenningerJ, Schneider HT, Schuppan D, etal. Acute hepatitis induced by greatercelandine (Chelidonium majus). Castroenterology. 1999 Nov;l17(5):l234-7.

7. Baumann JC. [Effect of Chelidonium, Curcuma, absintb and Carduus marianuson the bile and pancreatic secretion in liver diseases.] Med Monatsschr.1975;29:173-80 [in German].

8. Hiller KO, Chorbani M, Schilcher H. Antispasmodic and relaxant activity ofcheiidonine, protopine, coptisine, and Chelidoniiitn ma/us extracts on isolatedguinea-pig ileum. Planta Med. I998;64:75fl-60

9. Hriscu A, Galesanu MR, Moisa L. Cholecystokinetic action of an alkaloidextract of Chelidonium mains. Rev Med Chir Soc Med Nat Lasi. 1980;84r559-61

10. Mitra S, Gole K, Samajdar K, et al. Antihepatotoxic activity ofChelidonium tnajus. Int I Pharmacognosy. !992;30:125-8.

11. Mitra S, Sur RK, Roy A, Mukherjee AS. Effect of Chelidor)ium ma/us L onexperimental hepatic tissue iniury. Phytother Res. 1996;10:354-6.

12. Blumenthal M, ed. The Complete German Commission f Monographs.-Therapeutic Cuide to Herbal Medicines. Klein S, trans. Boston, MA: AmericanBotanical Council, 1998.

13. Lin SC, Lin CH, Lin CC, et al. Hepatoprotective effects of Arctium lappa Linneon liver injuries induced by chronic ethanot consumption and potentiated bycarbon tetrachloride. I Biomed Sci. 2002;9;401-9.

14. Lin SC, Chung TC, Lin CC, et al. Hepatoprotective effects of Arctium lappaon carbon tetrachloride- and acetaminophen-induced liver damage. Am I ChinMed, 2OOO;28(2):163-73.

15. Schuiz V, Hansel R, Tyler VE. Rational Phytotherapy: A Physician's Guide toHerbal Medicine. Telger TC, transl. 3rd ed. Beriin, Germany; Springer; 1998.

16. Kim DH, Jin YH, ParkJB, Kobashi K. Silymarin and its components are inhibitorsof beta-glucuronidase. Biol Pharm Bull. 1994;17:443-5.

17. Araujo CC, Leon LL. Biological activities of Curcuma tonga L Mem IrtstOswaldo Cruz. 2001;96:723-8

18. Antony S, Kuttan R, Kuttan G. Immunomodulatory activity of curcumin.Immunol Invest. 1999;28:291-303.

19. Deeb D, Xu YX, Jiang H, et al. Curcumin (diferuloyl-methane) enhances tumornecrosis factor-related apoptosis-inducing ligand-induced apoptosis in LNCaPprostate cancer cells. Mol Cancer Ther. 20O3;2;95-tO3.

20. Rukkumani R, Aruna K, Varma PS, Rajasekaran KN, Menon VP. Comparativeeffects of curcumin and an analog of curcumin on alcohol and PUFA inducedoxidative stress. / Pharm Sci. 2004 Aug 2O;7(2}:274-83.

21. Bruck R, Ashkenazi M, Weiss S, et al. Prevention of liver cirrhosis in rats bycurcumin. Liver Ini. 2007 Apr;27(3):373-83.

22. Kraft K. Artichoke leaf extract- recent findings reflecting effects on lipidmetabolism, liver and gastrointestinal tracts. Phytomedicine. 1997;4:369-78.

146 TOWNSEND LETTER - DECEMBER 2007